February 2020

AIHC Monthly Newsletter

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 January 2020

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In This Newsletter



HIPAA Final Rule - HITECH Update January 2020


The Office for Civil Rights (OCR, HIPAA Privacy/Security enforcement agency, reports that on January 23, 2020, a modification has been made to the 2013 Omnibus Final Rule (Final Rule).  A portion of the 2013 Final Rule was challenged in federal court, specifically provisions within 45 C.F.R. §164.524, that cover an individual’s access to protected health information. 

  • A Federal court vacated the “third-party directive” within the individual right of access “insofar as it expands the HITECH Act’s third-party directive beyond requests for a copy of an electronic health record with respect to [protected health information] of an individual  . . . in an electronic format.”
  • Additionally, the fee limitation set forth at 45 C.F.R. § 164.524(c)(4) will apply only to an individual’s request for access to their own records and does not apply to an individual’s request to transmit records to a third party.

Result?  The right of individuals to access their own records and the fee limitations that apply when exercising this right are undisturbed and remain in effect.  OCR will continue to enforce the right of access provisions in 45 C.F.R. § 164.524 that are not restricted by the court order. 

A copy of the court order in Ciox Health, LLC v. Azar, et al., No. 18-cv-0040 (D.D.C. January 23, 2020), may be found at https://ecf.dcd.uscourts.gov/cgi-bin/show_public_doc?2018cv0040-51 


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Coding - the Link Between Diabetes and Kidney Disease


Chronic kidney disease “is the under-recognized public health crisis,“ according to the National Kidney Foundation. With diabetes being the leading cause of this disease, it is important to recognize the impact both of these conditions are having on the population.

There are combination codes in ICD-10-CM when documentation from the treating provider links these conditions.  Click Here to read the full article! 


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HIPAA, Billing and Improved ASETT

Complaint(s) Enforcement Statistical Reports


The Division of National Standards announced the release of revised statistical reports regarding the CMS HIPAA complaint enforcement program.

The Complaint Enforcement Program supports implementation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) adopted Administration Simplification standards for transactions, code sets, unique identifiers, and operating rules.


Adopted Standards and Operating Rules

HIPAA required HHS to establish national standards for electronic transactions to improve the efficiency and effectiveness of the nation's health care system.   These standards apply to all HIPAA-covered entities:

  • Health plans
  • Health care clearinghouses
  • Health care providers who conduct electronic transactions, not just those who accept Medicare or Medicaid

Any provider who accepts payment from any health plan or other insurance company must comply with HIPAA if they conduct the adopted transactions electronically.  These providers must also have written agreements in place to ensure business associates comply with HIPAA. Examples of business associates include clearinghouses and independent medical transcriptionists.


Revised Statistical Reports

The revised statistical report(s) will illustrate to external stakeholders the quantity and quality of complaints received by CMS. In addition, the revised statistical report(s) will provide complaint types submitted by covered entities, violations based on type of transaction, and resolution time frames. Based on industry feedback, the government believes these revised reports can provide greater insight and foster increased collaboration with covered entities to achieve full compliance with HIPAA Administrative Simplification. 

CMS welcomes feedback and comments.  To share questions or comments, contact AdministrativeSimplification@cms.hhs.gov.

  • Click Here for HIPAA Enforcement Statistics
  • Click Here for the CMS Complaint Enforcement Program
  • Click Here for the Adopted Standards & Operating Rules Page


Obtain additional training in this area by attending the HIPAA Privacy/Security training camp – or Click Here for the online program.



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Billing “Incident-to” Inappropriately Leads to $285,000 Settlement


January 24, 2020 Family physician Dr. Chang-Wen Chen paid $285,000 due to improperly charging for physician’s care when services were actually provided by nurse practitioners NOT under direct supervision to Medicare, Tricare, and Medicaid.  The government alleged that Dr. Chen’s practice unlawfully billed government payers at the physician rate even when unsupervised nurse practitioners rendered services.

TRICARE always pays the reduced rate for services rendered by non-physician providers regardless of whether a physician supervises.  The government alleged that Dr. Chen’s practice unlawfully billed government payers at the physician rate even when unsupervised nurse practitioners rendered services.

Medicare requires the physician to be present in the office suite when filing claims in the office under “incident-to”. 

Read More – from the Department of Justice about this case Click Here

Need to learn more about “incident-to”?  Please reference the CMS manual for compliance – Medicare Benefit Policy Manual Chapter 15, Section 60.1 and discuss within your organization.  Learn to conduct internal audits – become a professional healthcare auditor.


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EHR Vendor Practice Fusion Pays $145 Million 


On January 27, 2020, the Department of Justice announced the Electronic Health Record (EHR) technology developer is paying $145 million to settle allegations that Practice Fusion extracted unlawful kickbacks from pharmaceutical companies in exchange for implementing clinical decision support (CDS) alerts in its EHR software designed to increase prescriptions for their drug products.

Practice Fusion’s conduct is abhorrent.  During the height of the opioid crisis, the company took a million-dollar kickback to allow an opioid company to inject itself in the sacred doctor-patient relationship so that it could peddle even more of its highly addictive and dangerous opioids,” is a statement made by Christina E. Nolan, U.S. Attorney for the District of Vermont. 

The CDS alerts that Practice Fusion agreed to implement did not always reflect accepted medical standards.  In discussions with pharmaceutical companies, Practice Fusion touted the anticipated financial benefit to the pharmaceutical companies from increased sales of pharmaceutical products that would result from the CDS alerts.  Between 2014 and 2019, health care providers using Practice Fusion’s EHR software wrote numerous prescriptions after receiving CDS alerts that pharmaceutical companies participated in designing.


ONC and the CMS EHR Incentive Program-Related Issues

In addition to the kickback allegations, the civil settlement with the United States resolves allegations relating to two intersecting Department of Health and Human Services (HHS) programs, one at the Office of the National Coordinator for Health Information Technology (ONC) that regulates the voluntary health IT certification program, and one at the Centers for Medicare & Medicaid Services that oversees EHR incentive programs.  Specifically, the United States alleged that Practice Fusion falsely obtained ONC certification for several versions of its EHR software by concealing from its certifying entity, known as an ONC-Authorized Certification Body, that the EHR software did not comply with all of the applicable requirements for certification.


First-Ever Criminal Action Against an EHR Vendor

The criminal Information charges Practice Fusion with two felony counts for violating the Anti-Kickback Statute (AKS), 42 U.S.C. § 1320a-7b(b)(1), and for conspiring with its opioid company client to violate the AKS, 18 U.S.C. § 371.  This case is the first-ever criminal action against an EHR vendor and the unique Deferred Prosecution Agreement imposes stringent requirements on Practice Fusion to ensure acceptance of responsibility and transparency as to its underlying conduct, and to invest heavily in compliance overhauls and an independent oversight organization

Click Here to read details about this case from the DOJ


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Braking Point Recovery Pays $24,479,939 Restitution and Owner Serving 7 ½ Years in Prison for Medicaid Fraud

 Medicaid Fraud by Braking Point Recovery Owner Ryan Sheridan

January 22, 2020


Ryan Sheridan was the sole owner of Braking Point Recovery Center, which operated drug and alcohol rehabilitation centers in Austintown and Whitehall, Ohio, that provided detox, intensive outpatient treatment, day treatment and residential living rehabilitation.  Sheridan also owned and operated numerous other businesses, including Breaking Point Health and Fitness LLC and Braking Point Recovery Housing LLC, which owned recovery houses (or “sober houses”) for individuals attempting to maintain abstinence from drugs and alcohol.

Sheridan and various other defendants submitted or caused to be submitted billings to Medicaid for drug and alcohol services that were:

  • coded to reflect a service more costly than was actually provided;
  • without proper documentation;
  • without proper assessment documents containing valid diagnosis;
  • billings for patients whose records did not contain diagnosis by a physician;
  • related to treatment at unlicensed inpatient beds;
  • billings related to dispensing of Suboxone, even though the treating physician did not have the authority to do so;
  • for case management services when, in fact, the clients were working out at Sheridan’s gym;
  • billings based on quotas provided to the nurses by the defendants to bill four to five hours of treatment daily, even if the services were not medically necessary;
  • billing for in-patient detox and drug treatment services that were, in fact, provided in an out-patient setting, among other violations.


Braking Point submitted approximately 134,744 claims to Medicaid for more than $48.5 million in services it claimed to provide between May 2015 and October 2017. Sheridan was also ordered to pay $24,479,939 in restitution and sentenced to 7 ½ years in prison.

Read More – from the Department of Justice about this case Click Here



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Next Generation Sequencing – CMS Expands Coverage

Decision Memo for Next Generation Sequencing (NGS) for Medicare Beneficiaries with Advanced Cancer (CAG-00450R) Announced by CMS January 27, 2020


The Centers for Medicare & Medicaid Services (CMS) has determined that Next Generation Sequencing (NGS) as a diagnostic laboratory test is reasonable and necessary.  CMS announced that NGS is covered nationally when performed in a CLIA-certified laboratory as long as it is ordered by a treating physician when all of the following requirements are met:

The patient has:

  • ovarian or breast cancer; and
  • a clinical indication for germline (inherited) testing for hereditary breast or ovarian cancer; and
  • a risk factor for germline (inherited) breast or ovarian cancer; and
  • not been previously tested with the same germline test using NGS for the same germline genetic content.

The diagnostic laboratory test using NGS must have all of the following:

  • Food and Drug Administration (FDA) approval or clearance; and
  • results provided to the treating physician for management of the patient using a report template to specify treatment options.


Click Here for the Decision Summary on cms.gov website.


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Coding - New ICD-10-CM Code Effective April 1, 2020

Update to the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) for Vaping Related Disorder

As of January 21, 2020, a total of 2,711 hospitalized EVALI cases or deaths have been reported to CDC from all 50 states, the District of Columbia, and two U.S. territories (Puerto Rico and U.S. Virgin Islands).  Sixty deaths have been confirmed in 27 states and the District of Columbia.

In response to recent occurrences of vaping related disorders, the Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics (NCHS) is implementing a new diagnosis code into the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), for reporting vaping-related disorder effective April 1, 2020.

The Grouper assigns each case into an MS-DRG based on the reported diagnosis and procedure codes and demographic information (age, sex, and discharge status). The new ICD10 MS-DRG Grouper software package to accommodate this new code, Version 37.1, is effective for discharges on or after April 1, 2020.


ICD-10-CM:         U07.0 Vaping Related disorder

Hospitals:            MS-DRG 205,206



CDC Announcement:     Click Here

CMS Announcement:     Click Here

MLN MM11623:             Click Here


Key to 2020 ICD-10-PCS Click Here – pre-approved by AIHC/AHIMA for 8 CEUs

Medical Office Coding – Fast-Track Comprehensive Course – Click Here



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Medicare Cost Reports 2020


Medicare-certified institutional providers are required to submit an annual cost report to a Medicare Administrative Contractor (MAC). CMS maintains the cost report data in the Healthcare Provider Cost Reporting Information System (HCRIS).  CMS has January 2020 Release Date information now available.  Click Here for the CMS Cost Report webpage.  Click Here to attend the March Medicare Cost Report Camp in Dallas – a 2 day training event worth 12 CPEs, 12 AHIMA/AIHC CEUs.


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Billing - Part B: Jan 2020 Immunization Educational Tool

Coding, Frequency Limits, Billing Information by Facility Type


CMS has posted a January 2020 Educational Tool for use by Hospitalist, SNFs, Home Health, RDFs, CORFs, RHCs, FQHCs, Hospices, HIS and CAH facilities.

The new educational tool provides billing information, medical necessity regarding billing frequency, CPT and HCPCS codes as well as Facility Type / Bill Type and Revenue codes for vaccinations.


Download this CMS tool – use the following URL or Click Here


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Compliance Violations and Hospice


Hospice organizations hold a special responsibility when providing all services related to the patient’s terminal illness and related conditions.  This includes ensuring the patient’s rights are respected.

Hospice and Non-Compliance to Patient Rights

CMS has published a January 2020 Fact Sheet “Safeguards for Medicare Patients in Hospice Care”.  This Fact Sheet contains important information for Hospice Providers and those with loved ones in hospice care.

When a hospice does not comply with Medicare requirements related to patient rights, there can be significant consequences. In these instances, abuse or neglect may occur, causing harm to the patient.


Examples of Abuse may include:

  • Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.
  • Verbal abuse includes the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability.
  • Mental abuse includes but is not limited to, humiliation, harassment, and threats of punishment or deprivation.
  • Sexual abuse includes but is not limited to, sexual harassment, sexual coercion, or sexual assault.
  • Physical abuse includes but is not limited to, hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment.
  • Neglect means failure to provide goods and services necessary to avoid physical harm or mental anguish.

CMS requires hospices to immediately report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source and misappropriation of patient property, by anyone furnishing services on behalf of the hospice, to the hospice administrator.

Enroll management and leadership in the $15 Ethics & Leadership online course – Click Here for more information – to help your organization develop a culture that drives ethical behavior.

Compliance and prevention of abuse should be part of all health care compliance programs.  Click Here for professional training in Corporate Compliance, an online certification program.

Click Here to download the Fact Sheet published January 2020 by CMS


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Medicare Cost Report Training Camp 

* REGISTRATION Closes as of March 1st!

Discounted Room Rates only guaranteed through Feb. 18, 2020 

  • March 11-12, 2020 in Dallas, Texas
  • This training camp is recommended for Chief Financial Officers, accounting staff, revenue cycle professionals, reimbursement professionals, and employees tasked with gathering information for Medicare cost reports at a healthcare organization.
  • Includes the option to certify as a Certified Cost Report Specialist (CCRSSM).


AIHC Members: Log in & register through the Member Store


HIPAA Privacy & Security Training Camp

  • April 29-30, 2020 in Las Vegas, Nevada
  • This training camp is designed for individuals with five (5) or more years of experience working with HIPAA compliance or healthcare compliance, preferably as a HIPAA Compliance Officer or healthcare compliance professional.
  • Includes the option to certify as a Certified HIPAA Compliance OfficerSM (CHCO).


AIHC Members: Log in & register through the Member Store


Medicare Cost Report Training Camp in Nashville

  • September 23-24, 2020 in Nashville, Tennessee
  • This training camp is recommended for Chief Financial Officers, accounting staff, revenue cycle professionals, reimbursement professionals, and employees tasked with gathering information for Medicare cost reports at a healthcare organization.
  • Includes the option to certify as a Certified Cost Report Specialist (CCRSSM).


AIHC Members: Log in & register through the Member Store


Corporate Compliance Training Camp

  • November 11-12, 2020 in Tampa, Florida
  • This program is recommended for healthcare professionals with medical compliance office experience or who are in need of additional healthcare compliance training.
  • Registrations Are Opening Soon


Online Training

Annual Staff and New Hire HIPAA Training

This short training program is designed for both new hires and healthcare professionals who are required to complete yearly HIPAA training.



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